Growth after renal transplantation

Growth of kidney-transplanted pediatric patients treated with sirolimus

Experimental findings indicate that sirolimus (SRL) inhibits longitudinal growth by mechanisms potentially related to its inhibitory effects on both cell proliferation and expression of vascular endothelial growth factor (VEGF). The aim of this study was to investigate the growth pattern of kidney-transplanted children treated with SRL in a multicenter observational clinical study. Height, change in height SD (Δ height) and growth velocity of pediatric patients with renal transplant were calculated at 0, 6, 12, and 24 months after starting SRL. Controls of kidney-transplanted children not treated with SRL were matched by age, gender, renal function, and dose of corticosteroids. Sixty-eight children (34 SRL, 34 controls) were enrolled in the study. Nephrotoxicity was the most frequent indication to start therapy with SRL. SRL exerted an adverse effect on growth as demonstrated by significantly lower (p < 0.05) growth velocity (cm/year) and smaller change in height SD in the SRL group after 6 (4.08 vs. 6.56 and -0.05 vs. 0.14), 12 (4.44 vs. 6.11 and -0.03 vs. 0.28) and 24 (4.53 vs. 6.03 and -0.04 vs. 0.53) months of treatment. This study suggests that SRL therapy may interfere with growth of kidney-transplanted children. This undesirable effect needs to be taken into account when considering a switch to SRL and confirmed in further prospective trials including larger number of patients.

Solid-organ transplantation in childhood: transitioning to adult health care

Pediatric solid-organ transplantation is an increasingly successful treatment for solid-organ failure. With dramatic improvements in patient survival rates over the last several decades, there has been a corresponding emergence of complications attributable to pretransplant factors, transplantation itself, and the management of transplantation with effective immunosuppression. The predominant solid-organ transplantation sequelae are medical and psychosocial. These sequelae have a substantial effect on transition to adult care; as such, hurdles to successful transition of care arise from the patients, their families, and pediatric and adult health care providers. Crucial to successful transitioning is the ongoing development of a sense of autonomy and responsibility for one's own care. In this article we address the barriers to transitioning that occur with long-term survival in pediatric solid-organ transplantation. Although a particular transitioning model is not promoted, practical tools and strategies that contribute to successful transitioning of pediatric patients who have received a transplant are suggested.

Outcomes in pediatric solid-organ transplantation

LaR Pediatric solid-organ transplantation is an increasingly successful treatment for organ failure. Five- and 10-yr patient survival rates have dramatically improved over the last couple of decades, and currently, over 80% of pediatric patients survive into adolescence and young adulthood. Waiting list mortality has been a concern for liver, heart, and intestinal transplantation, illustrating the importance of transplant as a life-saving therapy. Unfortunately, the success of pediatric transplantation comes at the cost of long-term or late complications that arise as a result of allograft rejection or injury, immunosuppression-related morbidity, or both. As transplant recipients enter adolescence treatment, non-adherence becomes a significant issue, and the medical and psychosocial impacts transition to adulthood not only with regard to healthcare but also in terms of functional outcomes, economic potential, and overall QoL. This review addresses the clinical and psychosocial challenges encountered by pediatric transplant recipients in the current era. A better understanding of pediatric transplant outcomes and adult morbidity and mortality requires further ongoing assessment.

Approach to optimizing growth, rehabilitation, and neurodevelopmental outcomes in children after solid-organ transplantation

One of the most critical differences between the posttransplant care of children and adults is the requirement in children to maintain a state of health that supports normal physical and psychological growth and development. Most children with organ failure have some degree of growth failure and developmental delay, which is not quickly reversed after successful transplantation. The challenge for clinicians caring for these children is to use strategies that minimize these deficits before transplantation and provide maximal opportunity for recovery of normal developmental processes during posttransplant rehabilitation. The effect of chronic organ failure, frequently complicated by malnutrition, on growth potential and cognitive development is poorly understood. This review presents a summary of what is known regarding risk factors for suboptimal growth and development following solid-organ transplant and describe possible strategies to improve these outcomes.

Maximizing growth in children after renal transplantation

Achieving normal height in children after renal transplantation is a crucial issue for both quality of life and self-esteem. The management of growth retardation in renal transplant recipients includes adequate nutritional intake, correction of acidosis, optimal drug compliance, limited calcineurin inhibitor nephrotoxicity, steroid-sparing strategies, and sometimes recombinant human growth hormone.

Prevalence and complications of chronic kidney disease in paediatric renal transplantation: a K/DOQI perspective

Background. Although renal transplant recipients (RTR) have been included as patients with chronic kidney disease (CKD) by the Kidney Disease Outcome Quality Initiative (K/DOQI), there are very few studies looking at CKD complications among paediatric RTR. Methods. CKD parameters of paediatric RTR with at least 1 year post-transplant follow-up were retrospectively reviewed as per K/DOQI criteria. Results. The study population included 129 RTR aged 2.7-20 (median 13.9) years, of which 67% were male and 87% Caucasian with follow-up between 1 and 14.8 (median 3.8) years. Sixty-six per cent of RTR were in either CKD Stage 3 (70) or 4 (15). A high incidence of CKD complications was identified (albuminuria 60%, anaemia 50%, acidosis 30%, hyperparathyroidism 20%, hypoalbuminaemia 16%, hyperphosphataemia 12% and hypocalcaemia 3%). Hypertension (defined as systolic blood pressure greater than 95th percentile for age and height or on any anti-hypertensive medication) was found in 53% (n = 68) of the study population, out of which 7% (n = 5) was having uncontrolled hypertension with systolic blood pressure greater than 95th percentile despite being on anti-hypertensive medication. There was an increase in complications (P = 0.0001) as well as use of CKD medications (erythropoietin-stimulating agent, sodium bicarbonate, 1-alfacalcidol and phosphate binders) across the CKD stages in RTR (P = 0.001). Conclusion. The study confirmed a high prevalence of CKD with its related complications along with increase in frequency of complications across the stages of CKD among paediatric RTR. Further multi-centre prospective studies are required to substantiate our findings and to explore whether early identification and intervention can improve renal allograft outcome.